Swasthya

The Centre for Cleft Services – St.Joseph’s Hospital recommends that children with clefts be seen by an team of doctors and care providers to best plan care and treatment. The team includes: • CLEFT surgeons - perform reconstructive and cosmetic surgery.
• Anesthesiologist – Gives anesthesia and looks after the patient in ICU.
• Pediatrician – Sees the baby from birth , advices on maintaining health and nourishment.
• Physician – Checks the patient for any systemic abnormalities.
• Otolaryngologist - ear, nose and throat doctor.
• Orthodontist - treats misaligned teeth.
• Speech pathologist - evaluates and treats speech, language, voice, swallowing, fluency, and other related disorders.
• Geneticist - diagnoses, treats, and counsels patients with genetic disorders or syndromes.
• Audiologist - diagnoses and treatment of hearing problems.
• Social worker - performs casework and counseling.
• Nurses - coordinates care, clinic visits, provides support and information.
All have many years of experience working with children with clefts and their families.
The first clinic visit usually happens in the first year, but not necessarily before surgery. For the first few years children are seen annually, but after that it may be every two or three years depending on the child and his/her needs. Certainly the family may always request an appointment.

Approximately 1 in 700 children born have a cleft lip or a cleft palate or both .A cleft is a fissure or opening—a gap. It is the non-fusion of the body's natural structures that form before birth. A cleft lip and cleft palate is a facial abnormality. It's caused by problems with facial development during gestation. There are various types of clefts, and they can be incomplete or complete. Being born with a cleft lip and/or palate (roof of the mouth) is a common birth defect. Having a baby born with a cleft can be upsetting, but cleft lip and cleft palate can be corrected. In most babies, a series of surgeries can restore normal function and achieve a more normal appearance with minimal scarring.

There are many causes of cleft lip and palate. Problems with genes passed down from one or both parents, drugs, viruses, or other toxins can all cause these birth defects. Cleft lip and palate may occur along with other syndromes or birth defects.

After a baby is born with a cleft, parents are understandably concerned about the possibility of having another child with the same condition. While many cases of cleft lip and cleft palate can't be prevented, consider these steps to increase your understanding or lower your risk:

Consider genetic counseling: If you have a family history of cleft lip and cleft palate, tell your doctor before you plan for family. Your doctor may refer you to a genetic counselor who can help determine your risk of having children with cleft lip and cleft palate.

Take prenatal vitamins: Taking a multivitamin before conceiving and during pregnancy may help reduce the risk of birth defects, such as cleft lip and cleft palate. If you're planning to get pregnant soon, begin taking a prenatal multivitamin now. Don't use tobacco or alcohol. Use of alcohol or tobacco during pregnancy increases the risk of having a baby with a cleft defect.

Intrauterine diagnosis of orofacial clefts is possible by ultrasonography. Complete clefts are easily seen at 16 weeks gestation, however incomplete clefts are seen more readily at 27 weeks. Palatal cleftsare difficult to visualise by prenatal ultrasonography .

Prenatal diagnosis can be done during routine screening and with high resolution ultrasonography. Counselling of the parents is very important part of the treatment for cleft patient as they have to learn varioys feeding methods to feed the child during infancy, also the parents should be psychologically prepared to be the part of the team for the management of the child.

Counselling is also important as sometimes parents may want to terminate pregnancy but parents must be explained about the treatment options available for cleft patients, but again if the child is syndromic and having other congenital anomalies also then it may be a indication for termination of pregnancy. Future of the diagnosis is fetal surgery which is yet to become practical.

Goals of Treatment:
The goals of treatment for cleft lip and cleft palate are to ensure the child's ability to eat, speak, hear and breathe and to achieve a normal facial appearance. Treatment involves surgery to repair the defect and therapies to improve any related conditions.

Surgery to correct cleft lip and palate is based on your child's particular situation. Following the initial cleft repair, your doctor may recommend follow-up surgeries to improve speech or improve the appearance of the lip and nose. Surgeries typically are performed in this order:


Cleft lip repair — between 1 and 4 months of age

Cleft palate repair — between 5 and 15 months of age

Seccondary surgeries — between age 2 and late sixteen years

Cleft lip and palate surgery takes place in a hospital. Your child will receive an anesthetic, so he or she won't feel pain or be awake during surgery. Many different surgical techniques and procedures are used to repair cleft lip and palate, reconstruct the affected areas, and prevent or treat related complications. In general, procedures may include:

Cleft lip repair: To close the separation in the lip, the surgeon makes incisions on both sides of the cleft and creates flaps of tissue. The flaps are then stitched together. The repair should create a more normal lip appearance, structure and function. Cleft palate repair: Various procedures may be used to close the separation and rebuild the hard and soft palate (roof of the mouth), depending on your child's particular situation. The surgeon makes incisions on both sides of the cleft and repositions the tissue and muscles. The repair is then stitched closed.
Ear tube surgery.

 For children with cleft palate, ear tubes also may be placed during the first surgery to reduce the risk of frequent ear infections, which can lead to hearing loss. Ear tube surgery involves placing tiny cylinders in the eardrum to prevent fluid buildup.

Surgery to improve cosmetic appearance:

 Additional surgeries may be needed to improve the appearance of the mouth, lip and nose. Surgery can result in significant improvement in your child's appearance, quality of life, and ability to eat, breathe and talk. Possible risks of surgery include bleeding, infection, poor healing, puckering of scars, and temporary or permanent damage to nerves, blood vessels or other structures.

Treatment for complications of cleft lip and cleft palate Your doctor may recommend additional treatment for complications caused by cleft lip and cleft palate. Additional treatments may include: Hearing aids or other assistive devices for a child with hearing loss Speech therapy to correct difficulty with speaking Therapy with a psychologist to help a child cope with the stress of repeated medical procedures.

A cleft lip and cleft palate are usually apparent at birth, and your doctor may start coordinating care at that time. If your baby has signs and symptoms of a submucous cleft palate, such as difficulty with feedings, make an appointment with your child's doctor.

Coming to clinic allows the family to see many of the child’s health care providers at the same time. This can save time and travel for the family. The clinic visit also gives the health care team the opportunity to discuss with each other and the families what may be the best plan for the child’s ongoing care with regard to cleft lip/cleft palate. The members of the team offer expertise in many issues about cleft lip/palate and can coordinate ongoing services.

Be aware of any pre-appointment restrictions. At the time you make the appointment, be sure to ask if there's anything you need to do in advance, such as restrict your baby's diet.
Write down any signs or symptoms your baby is experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
Consider taking a family member or friend along.Sometimes it can be difficult to remember all the information provided during an appointment. Someone who accompanies you may remember something that you missed or forgot.

What to expect from your doctor Your doctor is likely to ask you a number of questions. Being ready to answer them may allow time to cover other points you want to address. Your doctor may ask:
Does your family have a history of cleft lip and cleft palate?
Does your baby have problems while feeding, such as gagging or regurgitating milk through his or her nose?
Does your baby experience any symptoms that worry you?
What, if anything, seems to improve your baby's symptoms?
What, if anything, appears to worsen your baby's symptoms?

Depending on the width of the cleft and the presence or absence of a cleft palate, a short period of reshaping the mouth and nose may be recommended.

NAM is a technique in which the alveolus (gum ridges) and/or nose are molded with an appliance similar to an orthodontic retainer. This is usually done by a specially trained orthodontist prior to surgery, in order to make surgery simpler.  The baby wears the appliance 24 hours a day for a period of weeks or months.  It does not interfere with feeding or breathing for the baby.

Nearly all children with cleft palate need braces because the teeth closest to the cleft tend to come in at incorrect angles or not at all. Orthodontics may begin as early as age 5 or 6.

In some older children a “bone graft” is needed to allow the adult teeth to come in properly. Small bone fragments are taken from the hip and placed in the gap in the alveolus (bone edges of the gum) by an oral surgeon. This allows the adult teeth to have a solid surface to erupt into. The orthodontist and the oral surgeon will determine if this is necessary some time between ages 8 and 10.

For some children with more severe facial problems more oral surgery becomes necessary when they are teenagers. Orthognathic Surgery(OS) is a surgical technique in which bones in the jaw are cut and repositioned to make equilibrium of face. This procedure is usually done to advance the mid-face or upper jaw. After surgery the elastics are placed for 2-3 weeks and gradually adjusted, to stabilize the bones
What is Rhinoplasty Surgery? For children having the nasal deformity we do Rhinoplasty , As nose marks the prominent part of the face ,the correction is very important specially at the teen age . Rhinoplasty may require using cartilages from patient itself or any Implant material to improve the aesthetics , Patient has to have a plaster on the nose for about a week.